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Related Subjects: |Osteoporosis

Requires very prompt diagnosis & treatment to try and prevent catastrophic consequences of paralysis & incontinence. Give Dexamethasone 16mg immediately if malignant SCC diagnosis suspected unless contraindicated

About

• Medical/Oncological/Surgical emergency
• Spinal cord shorter than spinal canal and ends at L1 (UMN motor)
• Cauda equina compression is below L1 (LMN motor)

Causes

• Associated with trauma and fractures with bony fragments
• Haematoma - trauma and anticoagulants
• Epidural abscess
• Central disc prolapse
• Metastases - prostate, breast, lung, lymphoma

Clinical

• May have known malignant disease - prostate, breast, lung, lymphoma
• Backpain or root pain may be present
• Sensory and motor level below which there is reduced sensation and hyperreflexia and increased tone and upgoing plantar
• Root symptoms and often asymmetrical, numbness, paraesthesia
• Bowels and bladder as sphincters may be involved
• Cauda equina: saddle anaesthesia and LMN leg and sphincter weakness
• Look for breast mass or prostate enlargement, lung tumour , melanoma

Investigations

• FBC, U&E, LFT, ALP, PSA, PPE, ESR, BJP
• CT CAP, Mammogram
• MRI (CT of MRI not possible) of all spine looking for main lesion and any others which should be done within 24 hrs of presentation

Management

• Urgent Neurosurgical referral if unstable spine needing surgical decompression. Until spinal stability is confirmed patients should be managed on bed rest. Immobilise spine where spinal instability suspected. Ensure patient is nursed on flatbed and log rolled Get urgent imaging.
• Ensure adequate analgesia - may need opiates and manage constipation with laxatives
• If stable after treatment involves rehabilitation services early to support early discharge and improve quality of life.
• Manage bladder - may need catheter. Patients with urinary retention may need instruction on self-catheterization and indwelling catheter management
• Ensure VTE assessment as high risk of VTE
• Bowels depends on the level. If the lesion above T12-L1 the cauda equina is intact then spastic bowel; sacral reflex generally preserved. If below T12-L1 flaccid bowel (reflex arcs damaged) and so flaccid bowel; generally requires manual evacuation of the rectum. Most patients will need laxatives to prevent constipation.

Management Malignant Spinal Cord Compression

• Refer for a Neurosurgical consult if needed to stabilise the spine. Refer to Oncology for radiotherapy/chaemotherapy. Thoracic 60% and Lumbar 25% and Cervical 15%
• Malignant cause: Dexamethasone 16mg OM or 8mg BD (8am & 12noon) and add a PPI.
• Radiotherapy should be considered in all except those with total paraplegia (>24hrs) & no pain who have a very poor prognosis. Radiosensitive tumour like myeloma, lymphoma, breast, prostate and small cell lung cancer generally do better than radioresistant tumour such as melanoma and renal cell carcinoma
• Chemotherapy: for chaemosensitive tumour s, Hodgkin's lymphoma, Non-Hodgkin's Lymphoma, Neuroblastoma, Germ cell, Breast cancer (hormonal manipulation), Prostate cancer (hormonal manipulation)
• Median survival with MSCC is 6 months Ambulatory patients with radiosensitive tumour have the best prognosis

Spinal stability in metastatic spine disease is dependent on the following factors

• Site of disease(cervical, thoracic or lumbar): For example, in the thoracic spine the presence of ribs and chest wall provides added support to the spinal column affected by metastatic disease, whereas this is lacking in the cervical spine.
• Extent of tumour infiltration: In general, the greater the tumour involvement of the vertebrae, (particularly of the vertebral body) the more likely it is that stability is compromised. Collapsed vertebrae are also less likely to be stable.
• Co-morbidity: For example, pre-existing osteoporosis of the vertebrae (related to old age, chronic steroid use etc) will lead to weakened bones, which when infiltrated by tumour is likely to be less stable.
• Effect of open surgery or disease progression: Decompressive surgery alone may alter the stability status of the spine fixation. Spinal stability may also be compromised in some patients managed non-surgically, due to tumour progression. In this instance follow pathway for urgent radiotherapy

Prognosis: Median survival and 95% CI after diagnosis of MSSC

• Lung cancer 32 (23-41) Days
• Prostate cancer 114 (37-183) Days
• Breast cancer 74 (28-114) Days
• Lymphoma 226 (514) Days
• Myeloma 374 (219-589) Days
• Primary unknown 41 (28-54) Days

References

• METASTATIC SPINAL CORD COMPRESSION
• Recognition & Treatment of Malignant Spinal Cord Compression Study Day